Increasing Access to Diagnostic Imaging in Developing Countries: The Asha Jyoti Mobile Clinic Nandish Shah1, Dr. Kathryn Everton1, Anna Nordvig1, Bianca Nguyen1, Dr. Niranjan Khandelwal2, Dr. Daniel Mollura1

1RAD-AID International, United States; 2Post-Graduate Institute of Medical Education and Research, Chandigarh, India

Introduction

Diagnostic imaging plays an important role not only in identifying pathology and

tracking the progression of a disease, but also in preventing disease via

screening. However, according to the WHO, one-half to two-thirds of people in

the world lack adequate access to basic imaging technology, such as x-ray and

ultrasound. This figure remains unchanged from WHO estimates from the late

1970s and early 1980s. It is therefore essential to learn how to measure access

in order to best improve it.

The Definition of ‘Access’ The WHO defines it as an interaction of different factors, which include

availability, affordability, accessibility, appropriateness, acceptability, and quality.

Essential Imaging for the Developing World

Interestingly, 80-90% of the imaging need in developing countries can be met

by x-ray and ultrasound alone. These modalities not only diagnose disease, but

have been shown to impact clinical management and patient outcomes in low-

resource settings.

X-rays are essential in the diagnosis and treatment for people presenting with

pulmonary or orthopedic conditions. Regarding screening, they can screen for

breast cancer through mammograms and osteoporosis through DEXA.

Ultrasound has an established role in obstetric imaging. Additional conditions

for its use include: abdominal trauma (FAST), cardiac valvular disease, and

image guidance for procedures. Regarding breast pathology, US can be used to

evaluate findings on mammography or screen women with dense breast tissue.

Also, it can identify breast cysts and provide image guidance for biopsy.

Understanding Adequate Access

Disparity in access also exists within developing nations, specifically between

the private and public sector. While the private sector has the resources to offer

needed imaging services, it is inaccessible to many due to cost and urban

location. The public sector, however, aims to provide for all, but is overburdened

due to a lack of sufficient resources both in trained staff and imaging devices.

For public-sector facilities in more rural areas, the challenge lies in having the

resources to house, maintain, and repair the most basic imaging services as

well as entice trained staff to stay in the area to offer services.

At the core, a definition of need has to be compared with a definition of

adequate access. After looking at data from the WHO, it is easy to see that

developing countries have not reached the capacity to provide adequate access

to both x-ray and ultrasound technology.

Background

RAD-AID International has looked at the issue of access through its

Radiology Readiness survey, a 16 part survey that attempts to reveal the

infrastructural, educational, financial, and clinical barriers surrounding access.

In 2010, a RAD-AID team administered it at several sites in India. In addition to

understanding barriers, the comprehensive survey helps identify areas of

medical need. In India, the survey revealed women’s health as the most

underserved and highest priority area of need.

Currently, about 70% of people in India reside in rural areas, where patients

lack basic health care to meet medical needs. The dearth of women’s health

screening programs results in increased morbidity and mortality from

preventable and treatable diseases. In fact, there is no national screening

program for breast cancer in India. Thus, when women do present to clinics and

hospitals, a majority of the new diagnoses are of locally advanced breast

cancer. Cervical cancer, which is second in prevalence to breast cancer, also

lacks adequate screening around India. Screening is also available for

osteoporosis, a condition affecting almost 1 in 3 low-income women in India.

Through survey data and an understanding of the medical needs, the team

decided to collaborate with a prominent government hospital, Postgraduate

Institute of Medical Education and Research (PGI), in Chandigarh, one of the

sites visited. Together, they started the Asha Jyoti Mobile Health Program.

Mission

The Asha Jyoti Mobile Health Program is a sustainable and scalable mobile

healthcare van program that uses radiologic technology and community health

services to address women’s preventative health issues in the city periphery

and rural areas near Chandigarh, Punjab.

The mobile health clinic will focus on providing free preventative screening

services for women:

1. Mammography (women 40+)

2. Cervical cancer screening (women 30+)

3. Bone densitometry screening (women 40+)

Patient Visit Results

Chandigarh is divided into sectors. Currently, the van goes to an existing

primary healthcare center in sector 45 for 3 days/wk. Sector 45 in Chandigarh is

a unique area with a combination of urban, rural (Burail village) and urban slum

population (colony 5). To reach them, the van sets up camps in remote village

and select urban areas. To date, the program has screened 2904 women.

Van Staff -Public Health Nurse

-Staff Nurse from PGI

-Technologist

-PGI Radiology

Resident

-Data Entry Operator

-Social Health Worker

-Driver

Technology On the mobile unit:

•Software for machines; a text messaging interface

•Central storage system, computer, and printer

•A portable data storage device

On site at PGI, the plan relies on the following systems:

•Central server using DICOM images and network

connection

•Eventually an EMR system and PACS system

Challenge Partnerships

1. Perception that screening

is unnecessary

Through a partnership with the School of Public

Health (SPH) at PGI, Asha Jyoti provides

community education programs.

The SPH helps identify community liaisons in

each target village to be health educators. These

women educate people on the benefits of

women’s preventative health care screening.

The community liaisons facilitate continuity of care

by keeping in touch with social workers at PGI

and ensuring follow-up care as necessary.

Constant feedback from the community liaisons

regarding challenges that arise will allow the

program to reassess and improve the outreach

and education strategies

2. Low income groups

believe they cannot afford

screening or treatment, or

take off work to seek care

3. Stigma of having cancer:

fear that one will become a

social outcast

4. Lack of awareness of

screening services

Addressing Challenges through Partnerships

Availability A medical device is able to be purchased on the market. Also applies

to functional medical devices that are physically available at health

care facilities

Affordability Medical device is a cost-effective option for both the patient and health

care facility

Accessibility Individuals are geographically within reach of health care facilities that

house imaging technologies

Appropriateness A medical device or imaging technology must be scientifically valid,

address local need, and be utilized in a manner that a country can

afford

Acceptability Refers to cultural beliefs and individuals’ attitudes regarding the use of

various medical devices and imaging modalities

Quality Based on the national regulatory standards that are in place to assure

safe and effective use of all health technologies

Measuring Access

In 1979, the WHO conducted a survey to assess radiological services and

received responses from 89 countries of varying income levels.

In 2010, the WHO disseminated the Baseline Country Survey on Medical

Devices, a two page survey to understand the factors that make up ‘access.’ It

was administered to the ministries of health in 145 WHO member countries.

Needs Assessment for Medical Devices: Published by the WHO in 2011. It

outlines how a country can calculate gaps in access to medical devices.

Simply, a nation can catalog what exists regarding imaging technology

with what should be available to better define their gap in care.

Conclusion

The first step in attacking the issue of access is to understand its various

components as outlined by the WHO. Next, from looking at WHO surveys, it is

easy to see a disparity in the access to medical imaging technology, among all

modalities, between the developed and the developing world. Now, with the

needs-based assessment in place, the WHO has laid the foundation for

uncovering the overall gap in adequate imaging technology. With this

information, all parties involved, whether it is radiologists, radiologic

technologists, sonographers, NGOs, ministries of health, or developing nations,

will be able to join forces to close this gap.

The Asha Jyoti clinic is an example of such a start.

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